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INTERVIEW

"New Treatments for Lung Cancer-" with Roman Perez-Soler.

Event_Moderator Welcome to WebMD Live. Today we will
be discussing "New Treatments for Lung Cancer-" with Roman Perez-Soler.

Dr. Roman Perez-Soler is an extensively published and highly regarded
academic and medical professional with specialties in internal medicine
and medical oncology. Dr. Perez-Soler, welcome to the show.

Dr. Perez-Soler Thank you.

Event_Moderator How would you define "malignant lung
cancer,' and isn't malignant lung cancer the only kind (as opposed to
benign)?

Dr. Perez-Soler There's really no benign lung cancer.
That doesn't really exist. When we use the word 'cancer," by definition
that means a malignant tumor, That's what cancer means. Therefore, anything
that grows in the lungs that's a tumor but it's benign, it's not a cancer,
That's rare, but it's possible to see a fatty collection of tissue, for
instance, that would never cause a problem.

Event_Moderator When a patient first receives a lung
cancer diagnosis, what are their treatment options? What new treatments
are available, and what kinds of costs are involved?

Dr. Perez-Soler It all depends on how expensive your
tumor is. It's what we call the 'staging' procedure. So if you're diagnosed
with cancer or your X-rays suggest it, basically you need to confirm
that first. That requires us to be able to access the area of abnormality,
takes piece of tissue, and send it to the pathologist. The pathologist
cuts and stains it in a special way, and looks under the microscope,
at which time he can tell whether this is an infection, malignant tumor,
or cancer. At that point, the doctor will tell you what the news is.
The next step before treatment can be recommended is to find out how
extensive the tumor is. It may be very advanced or not so advanced, so
at this point, we do the staging workup, which basically consists of
doing x-rays. So we do a CAT scan of the chest. Basically we only look
at the lungs. There is also a PET Scan, which is a new tool - still experimental.
We also look at the bones, and do a CAT scan of the abdomen. Also, I
always look at the brain. Maybe in 5 percent of people with a newly diagnosed
lung cancer, you may already find they have a spot in the brain, and
I think it's important that in the time the diagnosis is made, you look
at all of the body, as much as you can, so you have more information.
The more you get, the more effective treatment will be, and the least
amount of surprises you'll have. It's worth it. Then, we classify the
tumors from 1-4, and the reason for this is, by classifying them, it
provides prognostic information. A "1" is a small thing that can be taken
out by surgery and cured in relatively all, or most of the cases. Stage "2" means
cells have gone to the lymph nodes of the chest, and in stage '3' it's
more extensive. The nodes are on other sides of the chest. Stage "4" is
the worst. Disease isn't only in the lungs and chest, but outside of
the chest. It's the worst, and most difficult to treat. There are standard
treatments for each stage, meaning, what's been proven to be the best
way to help patients with treatments. Even if it's the best available,
standard treatment isn't always very good, so that means patients may
not want to do that. They may want to do something that may not be proven
but can possibly help them. Those are non-standard (experimental) approaches,
and when to use that is decided between the patient and the doctor. So,
the decision making of what to do with each patient is really the result
of a discussion between the doctor and patient once the staging and type
of cancer is known. The doctor needs to say 'the standard options are
'this,' and the results are 'this," or, 'there may be newer options,
but we don't yet know the consequences yet." If the newer options are
better than the standard ones, the patient may be the first to benefit.
So in almost every type or stage of lung cancer, there are standard and
experimental options. Each patient reacts differently to them. Some don't
like to take risks, some are more willing to do something newer than
what most patients do.

Event_Moderator Who gets lung cancer, primarily'? Is
smoking usually the culprit, or do hereditary factors play a big role
in this?

Dr. Perez-Soler That's a very good question, and it's
interesting to discuss this. There's no question that if you're a chronic
smoker, you have a higher risk of getting lung cancer, and other diseases.
Your risk depends on many things: the amount of cigarettes you smoke
each day, and the number of years you've smoked. That number is proportional
to the damage caused by tobacco inside your lungs. The other factor is
how good you are at repairing the damage caused by tobacco. Some people
are very good about it, some aren't. Some who smoke 1 pack a day have
a risk that may be smaller than other's. They're all exposed to the same
amount of poison, but genetically, some people are more capable of cleaning
the lungs of poison. Unfortunately, we can't yet recognize you can repair
the damage slowly, or who repairs it more fast, so we can't caution people
not to smoke, because of the way they are. Peter or Paul may smoke the
same amounts as you do. But we can generally say, DON'T SMOKE. Another
part of the story is how many people who get lung cancer never smoke.
Tobacco is a poison, but we all breathe many other things that are difficult
to distinguish .... it's easy with tobacco to determine exposure (the
answer is yes, or no, to the question of smoking), but we are all exposed
to other agents in the same amounts, which is why some who never smoke
can get lung cancer. I'd tell you about 20 percent of the patients we
see have never smoked. About 80 percent are current or past smokers,
and of them, I'd say the majority are past smokers. So what happens is
when people are young and they don't see it as a major risk, they'll
think they'll quit in a few years. Even it that occurs only for a few
years, you carry an increased risk. It you quit, it diminishes with time
(the risk), but you still carry the potential. Twenty percent (20%) of
the 170,000 people in the US who get this disease each year have never
smoked or been involved in the family, for example, with smoking. So
it's more complicated than just smoking. You're better off not smoking,
in general, we'll tell people. At the same time, you may smoke all of
your life, die at 80 and your lungs are clean. It's a genetic thing.
Some people are smart, some aren't, some are good at music, some aren't,
it's the same principle when some people can't clean their lungs of tobacco
smoking.

Event_Moderator So passive smoking does play a part?

Dr. Perez-Soler Yes, it does play a role, but as you
can imagine, the exposure of passive smokers is much lower than active
ones. It would take many more years of being in an environment where
people smoke a lot to get that exposure. If the people exposed are passive
smokers, that's not good. Again, we can't predict this beforehand, but
in a few years, we'll be able to, once we learn more about tobacco's
chemicals, what they do, and what the body does to get rid of that. We'll
be able to sort out those people, assuming tobacco still exists. If you
look at the numbers, approximately 25 percent of adults in this country
are active smokers, and the numbers haven't decreased much in the last
few years. Since the sixties, the numbers have decreased, and in the
last few years the numbers are actually rising with younger people. Tobacco
cessation hasn't worked the way we've wanted it to. About a quarter of
the population are active smokers, which tells us, this will still be
the first cause of cancer related deaths. About 1/3 of all cancer deaths
come from lung cancer.

Event_Moderator What is mesothelioma, and are there
different types, or degrees of this cancer?

Dr. Perez-Soler Mesothelioma is a rare form of lung
cancer, that originates not from the lung itself but from the surface
(rnesothelium) like an internal, very thin skin that covers the lung.
This is a rare disease, about 3,000 people get in the US each year. So
the classic lung cancer is about 170,000, numbers-wise, and mesothelioma
is about 3,000. This originates from the lung surface and looks different
during biopsy than the classical lung cancer. It tends to grow locally
so It doesn't spread outside of the chest like the other lung cancers,
Eventually it kills the patient, by local growth. So it becomes a very
big local problem, not from going outside. One of the characteristics
of this disease it is effects people that have been exposed. Not always,
but often, it affects those who have been exposed to asbestos. And again
there's a component of both active and passive asbestos exposures. Wives
of men who work in shipyards, for instance, can also get it. Anij the
exposure to asbestos is found in about 80 percent of the cases, I'd think
it's a lower number, about 50 pement. So again you may have never had
exposure to asbestos, or your husband may not have, and you could still
get it. It affects people in their 50s and 60s but we've also seen people
in 30s who get it. It's rare, but it's a disease that's been publicized
because of its clear risk factor. Asbestos exposure incidences should
go down, as asbestos In the workplace has decreased, but the numbers
haven't gone down dramatically, We don't think they'll lower much in
the future, and obviously in N. Europe and S. Africa (due to mineworkers)
it's very common over in those countries.

Event_Moderator How is the European medical community
equipped to deal with that?

Dr. Perez-Soler There has been a rather nihilistic
approach to the disease because of the fact that most patients who contract
the disease die within 6 to 18 months. So there has been a defeatist
approach because of the very aggressive and recalcitrant nature of this
tumor, so many in Europe and Britain have more or less resigned that
the patients will not survive, and therapy, many times, is only supportive.

Event_Moderator How many people are LIVING with lung
cancer? What kinds of survival and remission data are currently available?

Dr. Perez-Soler The numbers are the following. Each
year in the US there are 170,000 or more people diagnosed with lung cancer.
The latest figures are about 20 percent, So there should be about 20,000
people who are cured of it, however this doesn't mean they'll live forever.
Being cured means they'll be alive 5 years after diagnosis. After that,
because these people are generally in their 60s or 70s you'll see deaths
for other reasons, so it's hard to come up with a number of how many
people today in this country are considered cured of lung cancer (thinking
of cured as being alive 5 years later). So those who are cured have been
diagnosed before 1999. It's hard to calculate but they should be in the
numbers of at least 100,000. Also you have to know people that are cured
of 1 lung cancer are at risk of getting a 2nd lung cancer (2-3 percent
risk per year) So over time some develop a 2nd tumor. But I think there
should be at least 100,000 people cured of cancer in the US, and I'd
like to know who they are, because they can be a strong group of advocates
to spread Information available about this disease. People hear about
less lethal cancers, and one of the reasons is patients die pretty quickly.
Those that are actually cured are healthy.

Event_Moderator Which drugs are must prevalent in their
use in cases of lung cancer, and are there any herbs or vitamins that
might substitute or complicate prescription medications?

Dr. Perez-Soler About 10 years ago, many cases of advanced
lung cancer were not treated with treatments oncologists recommend (chemo)
because treatments were hard to take and were ineffective. So it debilitated
patients who went to unfriendly treatments causing tiredness, weight
loss, nausea, etc.; very little benefits. In the last seven to eight
years, we've had advances in 2 areas. First, new drugs have been developed,
and second we've learned to use chemo in a way that's better tolerated.
As a result, all patients with advanced lung cancer are offered chemo
and the chemo that most oncologists recommend is as follows. If you really
want to know what you should doctor, ask 'what would you do if you were
me?' So medical oncologists that see lung cancer need to be asked, 'what
would you take?" In general, they'd take a combination of two drugs:
Taxol, and Carboplatinum. If it's not exactly these 2, it's going to
be drugs that are very similar. So instead of Carboplatinurn it would
be cisplatinum, or Taxotere rather than Taxol. Fortunately, these aren't
the only drugs we have. There are other good drugs that are good but
aren't used as often. Gemcitabine is one of them, and this is a good
drug for what we call the non-small cell lung cancer. There are 2 major
types of lung cancer, one is 'non-small cell' and the other is 'small
cell.' Basically they're treated differently, or are at least perceived
to be. In non-small cell, it responds less frequently than small cell
in most patients. Gemcitabine is for non-small cell. Another new drug
is called Topotecan, and this one is basically good for small cell. So,
these are the drugs that one way or the other in combination people are
offered today and response rates depend on the type of lung cancer. If
it's non-small cell, you have to count on about a 30 to 40 percent real
tumor shrinkage, meaning you won't see shrinkage in 60 percent. It's
80 percent in other instances, and the shrinkage is temporary, sometimes
it's 3 months or it may be 1 or 2 years. There's no way to predict who
will be responding and for how long, so this is one of the problems we
have. We have to offer non-friendly therapies to people, and many times
these don't work. So more research in finding out which would be the
best drugs for each patient is the type of effort that needs to be encouraged
About vitamins and nutrition, many patients have the question, what should
I eat, what about vitamins and herbs? From a scientific point of view,
whether these things work or not, we don't yet know. We don't have the
study results. Supplements, etc, are non-toxic so they don't cause damage,
either. So my position and the position of most professionals is to be
tolerant and say there's nothing to lose by using this as an additional
thing, but there's no data to support that It helps. There's nothing
to lose. One thing people should know is vitamins and nutrients are probably
much more important in the progression of the damage of the lungs to
lung cancer. Most likely vitamins like Vitamin A have some protective
effect of those at risk for lung cancer, especially if they smoke. Epidemiological
studies have observed this for years, and have shown people whi died
that were rich in these types of vitamins had lower results of lung cancer.
Eighty percent (80%) of patients in Japan had that occur, nad the incidence
is lower in the US. It may be Japanese tobacco, or it may be that their
bodies or constitution of weather are different, it's hard to tell. It
may be genetic disposition, thought that's hard to believe. When Japanese
people come to the US, they develop lung cancer as much as us, which
may imply something that is a protectant in the Japanese diet. Perhaps
Green Tea or other herbs may protect. If you talk to scientists they'll
say it's much more likely vitamins/nutrition are important more so before
the cancer than after. To make the tumors disappear, you need much more
aggressive intervention like surgery, chemo, or radiation. Doctors should
be very tolerant and let patients know there's nothing to lose when asked
about the risks or benefits of vitamin therapy, There will be no side
effects and it will be very rare that they'll affect chemo negatively.

Event_Moderator {question presented} How long would
you have to be exposed to asbestos to be threatened?

Dr. Perez-Soler There is no clear answer to that question
because patients have reported extremely brief one day exposures, as
well as multiple everyday exposures in an occupation such as ship building,
and yet both develop mesothelioma. It appears, however, that the greater
the exposure over the course of time, and the amount of asbestos, the
greater the chance of contracting mesothelioma.

Dr. Perez-Soler Definitely, yes. For several reasons.
First because many times clinical trials allow access to something potentially
better. So, if you don't get in a clinical trial, you know what you're
getting. If you shop around, you may find one that suits your risk of
taking medications that would be better. There are some trials that are
better than others, and it also depends on what stage you have and what's
been tried on you. Certainly if you have standard chemo and the disease
comes back you'll probably want to try something new and will have to
enter a clinical trial, otherwise it won't be made available to you.
It depends. You have to look at what's involved, what you get, and the
potential. In general, you may not want to be involved in randomized
trials. Those trials are the perfect study from a scientific point of
view because it involves 2 groups of patients, 1 that gets 1 type of
standard therapy and the other that gets the potentially better therapy
(new drug combination, etc.). Obviously the patient wants new treatment--to
be in the 2nd group--but he has no control over that. He may only be
assigned to standard treatment. Many times standard treatment is a waste
of time for some stages. When it's good it can be very good, but if it
doesn't work it can be bad. So to take three or four months out of your
life for something that doesn't work, it's not a good deal. The FDA and
regulatory people find it's a definitive demonstration, but for patients
themselves it may not be the best trial. The best are the ones in which
you get the new drug and know that it works. You get the advantage of
the standard and the new drug. People recognize that by doing the trial
they have nothing to lose and maybe something to gain. If they're in
one that wastes their time with therapies that are defective, that's
something to consider. In general, you're more intensively taken care
of in trials, You're looked at more closely by research nurses, for example.
Everything is recorded and in the end you may even receive better care:
you come more often, tests are scheduled, you can contact the research
nurse at any time, and at the end this may translate into better clinical
care. So most of the time it's a good deal. All of us have had people
that have died in experimental protocols, obviously, so the question
arises, would they have died if they were not in the trial? So unfortunately
it doesn't always work.

Event_Moderator How has gene
therapy assisted in the treatment of lung cancer? Also, what is "phototherapy,"
and how is that utilized in cancer treatment?

Dr. Perez-Soler Gene therapy is a new form of experiment.
It's more a dream to invent a reality. But in my mind, it's one of these
possible dreams. Some dreams are impossible, and the reason they may
be so is we don't yet have the tools. In 1999, gene cell therapy is still
a dream. The idea is to be able to repair some damage that tobacco and
other poisons produce in the genes. The idea is to get the gene (piece
of DNA, a chemical) and examine it. To produce that gene from the call
isn't easy. Genes are large and don't cross the cell membranes, so a
technology has been developed for that, we're working on that. Hopefully
the gene can repair damage and replace missing genes. So it's a very
appealing strategy, as it goes to the essence of the problem, genetic
damage. It's one thing to have it in concept on paper, and to have it
work. It's like with airplanes, You can decide you'll make it fly, and
there are things to make it fly. That's where it is at this point. There
has been progress, and I think there's enough evidence to believe there
will be a way to do it, once it can be done effectively, we'll find some
diseases that can (and can't be) treated with this. It's more complicated
than just repairing genes.

Event_Moderator What's been the impact of this therapy
on lung cancer?

Dr. Perez-Soler There are several ideas and therapy
approaches being pursued in early experimental stages. Most imply putting
a needle in the tumor and injecting genes to destroy the tumors. We don't
yet have something definitive to tell patients, but we are making progress.
One of the things that's also being thought about is to use these genes
in other therapies in some type of inhaled device so that the poison
comes from the cigarette. There may be the drug or gene to repair that
damage, it may also be inhaled (a nebulizer type of machine) so the damage
can he repaired. We are exploring these concepts of gene therapy. It's
an early idea, and it will take time and effort to sort out the technical
problems. It's a dream that can be achieved in a few years.

Event_Moderator What is "tumor immunogenicity?"

Dr. Perez-Soler This is the ability of tumor cells to
trigger an immune response, and therefore by doing that, that immune response
can actually kill tumors. In a way it would be like showing your cards
to your enemy. Tumors are very smart. If you inject tumor cells in a patient,
even his own tumor cells, and you put them in blood, very few survive,
So the body's very good at ridding itself of suspect cells that don't follow
rules and create tumors. Some cells outsmart the system. The immune system
is like a police system that doesn't detect things that become tumors.
There's no police system in the body that can get rid of tumors after a
certain point. The ability of not being recognized as 'bad boys' is something
that immunogenicity does .... It's like the police recognizing 'bad boys'
on the street. If it's 3 am, they may suspect those people as the biggest
criminals of all, which tumors are. Tumors try to 'avoid suspicion,' and
by the time the immune system is aware, it's too late. So immunogenicity
can recognize this, when the call is made to the "police" and they arrive,
these tumors will secrete substances that antagonize the body's ability
to get rid of cells. Unfortunately, most tumors are not immunogenetic.
And they can't handle them because they can't neutralize an immune response.
The vaccine approaches haven't been successful so far. In 50 years we'll
have to look back to see how we can deal with lung cancers. As of today
we're pretty lost in terms of finding ways for the immune system to help
us eradicate lung tumors.

Event_Moderator {question presented} Would you say
the resources and treatment options are more cutting-edge in the United
States?

Dr. Perez-Soler Definitly, yes. Some people feel that
because of so much regulation in this country there are many options
available elsewhere. This has some validity. The rules here are pretty
stringent but at the same time the profit involved in having good cancer
medicines are so high, no one shies away in investing things that help
people, which in turn makes money. So for those reasons, the US has many
more options available, however it's true that many of these options
and protocols don't help the patient, so it's still harder to get access
because you may be in a clinical trial that is randomized. Again this
is dictated by the regulatory authorities. Many activists are involved
and many of them haven't been involved in the approval process of drugs.
The FDA has advocates who have had, say, breast cancer 15 years ago.
It's more "cosmetic," for the public to feel represented. The reality
is, if the FDA were infiltrated by people who have truly suffered from
disease, things would change. Drugs need to be offered by people who
are willing to take risks with different cocktails, etc. Some money needs
to be put aside for treatment of patients, at their own risk. People
are desperate. That makes the oncologists job hard - the patient realizes
not only he's in trouble and may die, but also the system is very difficult.
Sometimes this has more to do with psychology: comforting the patient
that the doctor has done everything they could do, and the patient may
be taking the best drugs, and that person would at least feel comfort.
Politics and administrators really don't care about the lives of people
and follow the rules, that's the type of message they get. That's why
there's so much emotional anger against the system, so that's why many
advocates should fight harder, for these reasons. Again, if something
goes wrong, it's absolutely at their own risk, and somee patients would
really go for that. They're desperate. Life is short. It's all we have.

Event_Moderator {question presented} Could you tell
the WebMD audience a little bit about the FDA Orphan Drug Act, and the
FDA Orphan Drug Program?

Dr. Perez-Soler We've said "bad things" about the FDA,
and it's really very respectable. They want to protect people against
the inherent desire drug companies have to make money. It drug companies
could make money by lying, they would do so also. The FDA provides protection
from that. If it would give access to drugs that are really good, that
would be the next step. As far as the drug act goes, that's been good.
Cancer is very profitable, in a sense, and all types of these diseases
have funding. So they have pooled money aside to give to researchers
and doctors who have ideas about this disease for research incentives.
They budget money each year and provide money to institutions who have "orphan
(more than 50,000 people who have the disease) indications." This has
allowed new things: treatment of an array of diseases. It's been several
million dollars, for sure that has been granted, and one of our studies
for mesothelioma was given some funding. It's not restricted to cancer,
it's for all array of diseases which are rate or for which there's not
given much funding for finding now cures or therapy.

Event_Moderator Where can I find resources on the Web
about the latest findings about treating lung cancer?

Dr. Perez-Soler There's a web site one of the patients
from NYU, where we are, has created called www.lungcanceronline.org.
I think it's the best site now for lung cancer. This is a good site Karen
Parles did on her own and the reason for it is, as a patient she realized
there was a need for consumer information on the internet so they could
look at different doctors, theories, and approaches. She had a rare form
of lung cancer and needed help from different doctors and opinions. She
realized there wasn't enough information she could really access. So
that's very helpful. She improves it all the time and it's a significant
effort. Eventually it could be "the place to go.'' So I recommend that,
as one of the best in terms of web sites for lung cancer.